What is the management approach for a patient presenting with subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Patients with subarachnoid hemorrhage require immediate transfer to a high-volume center (>35 SAH admissions annually) with multidisciplinary neurosurgical, neuroendovascular, and neurointensive care capabilities, followed by early aneurysm securing and aggressive management of complications in a specialized neurocritical care unit. 1, 2

Immediate Diagnostic Workup

• Obtain noncontrast head CT immediately for any suspected SAH, as CT sensitivity is 98-100% within 12 hours but declines rapidly to 93% at 24 hours and 57-85% by day 6. 1
• If CT is negative but clinical suspicion remains high, proceed directly to lumbar puncture looking for xanthochromia and elevated bilirubin, as misdiagnosis occurs in up to 12% of cases. 1
• Rapidly grade clinical severity using Hunt and Hess or World Federation of Neurological Surgeons scales, which is the single most useful predictor of outcome. 1

Initial Blood Pressure Management

• Control blood pressure with short-acting titratable agents to avoid both severe hypertension and hypotension until the aneurysm is secured. 1, 2
• Avoid hypotension strictly as it worsens cerebral perfusion and increases secondary brain injury. 1
• Gradual BP reduction is necessary when severely hypertensive, but the priority is preventing hypotension over aggressive BP lowering. 1

Emergency Aneurysm Securing

• Secure the ruptured aneurysm as early as feasible, which is the only proven method to reduce rebleeding risk and must not be delayed. 1, 2
• For anterior circulation aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping to improve 1-year functional outcomes. 1, 2
• For posterior circulation aneurysms, coiling is preferred over clipping. 2
• Evaluation by both endovascular and neurosurgical specialists is necessary to determine the optimal treatment approach. 2
• Partial treatment to secure the rupture site followed by delayed definitive treatment is reasonable if complete obliteration is not feasible acutely. 2

Neurocritical Care Unit Management

• Admit to a specialized neurocritical care unit with evidence-based protocols and frequent neurological assessments. 1, 2
• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset, to reduce the severity of neurological deficits from vasospasm. 2, 3
• If the patient cannot swallow, extract capsule contents with an 18-gauge needle into an oral syringe (labeled "Not for IV Use") and administer via nasogastric tube with 30 mL normal saline flush. 3
• Never administer nimodipine intravenously, as this can cause life-threatening hypotension. 3

Fluid and Hemodynamic Management

• Maintain euvolemia, not hypervolemia, as prophylactic hypervolemia has not improved outcomes and may be harmful. 1, 2
• Avoid prophylactic hemodynamic augmentation in patients at risk for delayed cerebral ischemia. 2
• Monitor with frequent vital signs and neurological assessments to detect early deterioration. 2

Acute Hydrocephalus Management

• Perform urgent CSF diversion via external ventricular drainage or lumbar drainage if acute symptomatic hydrocephalus develops. 1, 2

Delayed Cerebral Ischemia Management

• If delayed cerebral ischemia develops, induce hypertension while maintaining euvolemia unless baseline BP is already elevated or cardiac status precludes it. 1, 2
• Use transcranial Doppler to monitor for vasospasm, with Lindegaard ratios of 5-6 indicating severe spasm requiring treatment based on clinical situation. 2
• Consider endovascular therapies for refractory cases. 4, 5

Seizure Management

• Avoid phenytoin for seizure prevention as it is associated with excess morbidity and mortality. 2

Additional Supportive Measures

• Initiate venous thromboembolism prophylaxis once the aneurysm is secured. 1, 2
• Emergency reversal of anticoagulants if patient is anticoagulated. 1, 2
• Use standardized ICU care bundles for mechanical ventilation when required. 1, 2
• Implement validated dysphagia screening protocols. 2

Medications to Avoid

• Do not routinely use statins, intravenous magnesium, or endothelin antagonists, as they have not been shown to improve outcomes. 2

Dose Adjustments for Special Populations

• In patients with hepatic cirrhosis, reduce nimodipine to 30 mg every 4 hours with close blood pressure monitoring, as bioavailability is approximately doubled. 3
• Patients on strong CYP3A4 inhibitors should not receive nimodipine; those on moderate/weak inhibitors may require dose reduction if hypotension develops. 3
• Avoid grapefruit juice as it interferes with nimodipine metabolism. 3

Long-term Rehabilitation

• Implement multidisciplinary team approach to identify discharge needs and design rehabilitation. 1, 2
• Use validated screening tools for physical, cognitive, and behavioral deficits. 1, 2
• Provide interventions for mood disorders to improve long-term outcomes. 1, 2
• Perform cerebrovascular imaging after treatment and subsequent monitoring to identify remnants, recurrence, or growth of treated aneurysms. 2

Critical Pitfall to Avoid

The most devastating error is inadvertent intravenous administration of nimodipine, which can cause clinically significant hypotension requiring cardiovascular support with pressor agents and specific calcium channel blocker overdose treatments. 3